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Letter to the Editor: PNF and Gait Post-Stroke

      We read with interest the article by Gunning et al. (The Effectiveness of the Proprioceptive Neuromuscular Facilitation (PNF) Method on Gait Parameters in Patients with Stroke: A Systematic Review)1 and were moved to comment on the authors’ conclusions. The abstract of this article stated “current research suggests that PNF is an effective treatment for the improvement of gait parameters in patients with stroke”. Publication of such a statement led us to review the articles cited. We do not concur that these articles provide sufficient evidence that PNF is an effective treatment for improving gait parameters in patients with stroke. Our reasoning follows.
      • Gunning et al.1 presented a total of 5 articles, 4 of which are stated to have used an experimental design with samples sizes ranging from 18-40 participants. The fifth article was a larger, interventional study (n=340) that appears to be randomized but is not evaluated as such. None of the articles indicate a power analysis was performed a priori to ascertain whether the populations recruited would be adequate to observe differences. There was no indication of blinded assessments except in one study and no indication of concealed randomization sequence in the three of the four studies categorized as randomized trials. Further, one of the studies documented as a randomized trials was not randomized. Accordingly, the PEDro scores of three trials were 3-5, indicating “poor” or “fair” ratings, with one registering a “good” score (i.e., 7), with the fifth article rated using a different scale(min/max range of PEDro scores:0-10). Definitive conclusions drawn from three randomized trials of questionable quality is suspect.
      • Four of the five studies indicate no significant differences in any walking assessments recommended by published clinical practice guidelines for rehabilitation (i.e., gait speed or distance).2 In one study, there were no difference in any outcomes. In two others, differences were observed only in a subjective walking measure and, separately, in dorsiflexion during walking. In a fourth study, significant within-group gains were observed following PNF, although there is no presentation of the statistical evaluation of between-group differences. In summary, only one study demonstrates a significant between-group difference in walking speed using PNF vs another treatment.
      • Details of the experimental treatments utilized in most studies were absent, and most authors did not operationally define PNF. To our knowledge, PNF is not a single technique, but a treatment philosophy utilizing a variety of techniques based on both patients’ needs, and the training and interpretation of the practitioner. Although PNF was utilized in all studies, there was no agreed upon definition of what the treatments were or how they should be performed. There were also no details on the training provided to the therapists to perform PNF for consistency between therapists within a study. The combined concerns with methodology limits clinical applicability of the conclusions.
      • Additional details in the systematic review and the articles summarized demonstrate inconsistencies in reporting that raise concerns. For example, the systematic review excluded two articles that used PNF in combination with other treatments, although one included article incorporated other therapy activities with PNF. In one study, the authors indicated the inclusion of patients diagnosed with stroke of greater than 6 months duration, although the reported average duration post-stroke was less than 6 months in the sample recruited. These inconsistencies reduce the confidence in the methodology used to support the conclusions.
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